Transcript Introduction_to_Endoscopic_Skull_Base_Surgery

TUMOR CHARACTERISTICS
INTRODUCTION TO ENDOSCOPIC SKULL BASE SURGERY
Mohamed S. Kabil, MD Hrayr K. Shahinian, MD, FACS
Introduction
From its original reliance on microsurgical techniques, the field of
skull base surgery is currently being transformed into an
endoscopy-based specialty that is distinguished by excellent
outcomes, shorter operating times, faster recoveries, fewer
complications, and overall decreased patient morbidity. At the Skull
Base Institute in Los Angeles, California, these techniques are
routinely used in the surgical management of anterior, middle, and
posterior skull base tumors, both primary and recurrent, as well as
for various neurovascular compression syndromes, such as
trigeminal neuralgia, hemifacial spasm, and others. In our
experience, these endoscopic techniques have provided superior
access and resulted in better surgical results and an unsurpassed
intraoperative definition of neurovascular conflicts and tumor
morphologies. More than 90% of all patients undergoing endoscopic
skull base surgery are discharged from the hospital within 48 hours
of their operation.
OPEN TRANSCRANIAL
APPROACH
The Evolution from the Open Craniotomy to Fully Endoscopic
Skull Base Surgery
For decades, surgeons interested in the field of skull base surgery
have debated which techniques provide the best access to the skull
base with the least amount of associated risk. Traditional
approaches to the anterior, middle, and posterior skull base have
included complex transcranial or transfacial operations. These
procedures, facilitated by progress in the designs of surgical
instruments and advances in perioperative intensive care, have
afforded excellent exposure, allowing for complete removal of
massive tumors. However, these open procedures have also been
associated with significant morbidity and long-term convalescence:
the burden on the patient has been great. As a result, the evolution
of skull base surgery over the past decade has been characterized
by an emphasis on the development of minimally invasive
techniques that do not compromise surgical outcomes but do
significantly diminish the perioperative burden on the patient.
Endoscopic Skull Base Surgery in Practice
For the past decade at the Skull Base Institute in Los Angeles,
California, we have been performing endoscope-assisted and fully
endoscopic surgery of the anterior, middle, and posterior skull base.
Applications of endoscopy at our institution have included treatment
of primary and recurrent pituitary tumors (both with and without
suprasellar extension), treatment of the various neurovascular
compression syndromes (trigeminal neuralgia, hemifacial spasm,
glossopharyngeal neuralgia, spasmodic torticollis) at the
cerebellopontine angle (CPA), removal of vestibular schwannomas
and other CPA tumors, as well as resection of various other skull
base lesions, both malignant and benign.
For many indications, we now use only fully endoscopic techniques
via “keyhole” craniotomy access points; the need for extensive
craniotomies for intracranial exposure and retraction has been all
but obviated. Visualization of the relevant anatomy has proven to be
improved over microscopic imaging. Endonasal, transglabellar,
supraorbital, retrosigmoid, subtemporal, and other tailored keyhole
approaches have made virtually all skull base tumors amenable to
endoscopic resection.
PTERIONAL APPROACH
TRANSLABYRINTHINE APPROACH
FOR ACOUSTIC NEUROMAS
Conclusion
Selecting short, direct, and precise routes to lesions at the base of
the skull without manipulating and exposing unaffected areas is
essential for keyhole surgery. Rigid endoscopes of varying lengths
and angles of view have broadened the available surgical exposure
without the need for of additional dissection or retraction; the
resulting panoramic perspectives of the surgical field have allowed
for thorough evaluations of the extent of intracranial disease.
Progress is continuing, changing many scenarios in daily clinical life.
It is our hope that this work will contribute to the ongoing evolution
of minimally invasive skull base surgery.
INTRODUCTION TO ENDOSCOPIC SKULL BASE SURGERY
ENDOSCOPIC ENDONASAL
APPROACH
ENDOSCOPIC SUPRAORBITAL
APPROACH
ENDOSCOPIC RETROSIGMOID
APPROACH